1. Case Study 63: Cancer of the Female Breast
By Robyn Schwartz

2. Case Background 46, premenopausal Dense breasts
Has noticed cysts in the past
Noticed new lump in upper right quadrant
Did not resolve
Got bigger
Denied lumps in axillary

3. Patient history Happily married for 21 years 3 kids (3, 8, and 10)
Does breast self exams
Normal pap 2 years ago
Has Asthma and hypertension
Exercises
No tobacco, alcohol or illegal drugs

4. Risk Factors All 3 kids born after the age of 35
First period at 11yr old
Dense breasts
Cysts already develop regularly
Family history of breast cancer
Paternal grandmother diagnosed at age 45 before menopause
Mother diagnosed at age 45 before menopause. Died at age 73 from reoccurrence of breast cancer

5. Breast Cancer: What is it?
Uncontrolled division of abnormal cells in the breast
Caused by specific mutations
BRCA1 and BRCA2
TP53

6. Our patient: Mammogram
2.3cm x 2.9cm x 3.2cm mass
Irregular borders
Skin thickening
Enlarged axillary lymph node
6 Y-shaped microcalcifications extended toward nipple
Abnormal mass into pectoral muscle

7. Grading vs Staging How abnormal the cells are
1, 2, 3,4
Based on
Tubule formation
Size and shape of cells
Mitotic division
Measures the likely aggressiveness of the cells
How far the cancer has spread
I, II, III, IV
Based on
Size of tumor
Invasive vs non invasive
Spread to lymph nodes
Spread to other parts of the body

8. Grading tumors Tubular differentiation
Score 1: > 75% glandular/tubular
Score 2: 10-75% glandular/tubular
Score 3: < 10% Glandular/ tubular
Nuclear (size/shape)
Score 1: little variation in size
Score 2: moderate variability,
open vesicular nuclei
Score 3: lots of variability
open nuclei
Mitotic
Score 1: <7 mitoses
Score 2: 8-14 mitoses
Score 3: >14 mitoses

9. Staging Cancer agrdjdytydstasf Stage 0: No Cancer Stage I:
IA: Cancer is small, low grade and localized
IB: Cancer is large, low grade and localized
Stage II:
IIA: Tumor is 2-5cm but has not spread
IIB: Tumor is 2-5cm but has spread to lymph nodes
Stage III:
Tumor is larger than 5cm and has spread to multiple lymph nodes
Stage IV:
Cancer has spread to other parts of the body
agrdjdytydstasf

10. Our Patient: Biopsy and ultrasound
Non-cystic mass, solid appearing
Abnormal vascularity
Some skin thickening and mild tissue edema
Biopsy:
Consistent with infiltrating breast cancer
3-5 divisions per high power field
Mild pleomorphism
Positive for estrogen and progesterone receptors

11. Grade and Stage Stage IIB Grade 1 Mitotic score: 1 (<7 divisions)
Glandular Score: 1 (75% glandular)
Nucleic Score: 1 (not much change)
Total score: 3
10 year survival rate 90%
Stage IIB
Small
Spread to 1 lymph node
5 year survival rate of 71%

12. Our Patient: Treatment
Breast conservation therapy
Lump removal
Radiation
Lymph node biopsy
Tamoxifen
Estrogen receptor blocker
Helps stop growth of cancer cells

13. Our Patient: Follow Up 6.5 years cancer free
80 months later, complained of
bone pain in lower back
Headache

14. Test Results Bone scan Chest X-Ray Brain MRI Abdominal CT Blood tests
Lesions in lumbar spine
without fracture
Chest X-Ray
3 small nodules in upper lobe of
left lung
Brain MRI
Small mass in right frontal lobe
Abdominal CT
Negative
Blood tests
CEA elevated by 2-fold
CA27-29 concentration elevated by 2-fold

15. Diagnosis, Outlook, and Treatment
Stage IV Breast cancer
13% 10-year survival rate
Treatments
Chemotherapy
taxanes
Hormone Therapy
Targeted therapy
HER2 targeted therapy
Slow growth
Manage Bone Metastasis
Biophosphonates
Slow destruction

16. How to Prevent cancer Exercise Eat well Don’t smoke
Do regular breast self exams
Report anything suspicious immediately
Check family history